Utilization Management:
Caring Before, During, and After Hospitalization

Members have a lot of questions before checking into the hospital for surgery, and it’s the Utilization Review Nurses for MedCost who help answer those questions and proactively plan for a member’s discharge from the hospital. Utilization Review (UR) is a comprehensive program that guides members through the sometimes complicated health care system and helps them get back home, in their own beds, for recuperation while still providing the care they need.

“After discharge, it is our primary objective to give members the one-on-one attention they need to recuperate quickly, safely, and comfortably.” Renee Pulliam, Manager of MedCost’s Utilization Management Services

Because being well-prepared for surgery is the first step to a faster recovery, MedCost has expanded our pre-operative education to include back and cardiac surgeries, at no additional cost to employers. The Utilization Management department gives members a friendly, knowledgeable point of contact within the MedCost network.

A few days prior to hospital admission, the member receives a call from one of MedCost’s skilled UR Nurses. During this initial call, the member learns what to do prior to surgery to prepare for post-surgery recuperation. For those having joint replacement surgery, for example, a UR nurse may suggest moving any furniture that could hinder mobility with a walker, advise the removal of rugs or other trip and fall hazards, and stress the importance of placing a phone and important phone numbers within reach of the bed. During the member’s hospital stay, UR nurses communicate with doctors and hospital staff to anticipate any prescriptions or medical equipment the member may need after discharge and locate the best possible in-network source. They also work to negotiate discounted rates for prescriptions, equipment, or services that fall outside a member’s health plan. This work is done behind the scenes, to make the member’s transition home as comfortable as possible. Members feel more prepared and are able to focus on recuperation rather than having prescriptions filled and purchasing medical equipment.

Once the member is released from the hospital, a UR nurse is in contact within 24 hours to answer any questions and make sure the member understands the course of home treatment. This could mean explaining why a medication was prescribed, stressing medication and treatment compliance, identifying when a member should call the doctor, and offering helpful hints about comfortable resting positions. Post-operative education counseling also has been expanded for patients with complicated hospital or neonatal cases or those diagnosed with deep vein thrombosis (DVT), pulmonary embolism (PE), chronic obstructive pulmonary disease (COPD), or diabetes.

The same UR Nurse may follow a member through any subsequent hospitalizations or surgeries. “It gives members a feeling of reassurance to know the nurse they spoke to two years ago for their joint replacement surgery can also assist them in their current surgery,” Renee says. “The goal of our Utilization Management department is to provide members with the highest level of care and comfort before, during, and after their hospital stay.”

The addition of back and cardiac pre-surgery education along with more comprehensive post-operative education counseling, at no additional cost to the employer, makes the Utilization Management program an exceptional value for employers while providing members with the best quality health care available. This hands-on approach and one-on-one interaction has decreased the number of member hospital readmissions and post-surgery medical claims.